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C D A J O U R N A L , V O L 4 6 , Nº 1 0

The Pinhole Surgical Technique:

A Clinical Perspective and
Treatment Considerations
From a Periodontist
Tina M. Beck, DDS, MS

A B S T R A C T Multiple treatment options exist when considering therapeutic

approaches for the management of gingival recession. The patented Pinhole Surgical
Technique is one of the most recent of such procedures and one of the most poorly
understood. The following commentary is intended to help guide clinicians in the
decision-making process when considering root-coverage strategies.


Tina M. Beck, DDS, MS, is umerous therapeutic change the gingival phenotype and
a diplomat of the American solutions have been increase the band of attached keratinized
Board of Periodontology proposed for the treatment gingiva.2–5 I was initially hesitant to
and a solo practitioner in
San Diego. Her professional
of gingival recession.1 offer PST as a viable treatment option
career has been dedicated One of the most recent because of the lack of long-term studies,
to leadership in organized root-coverage techniques, the Pinhole specifically on its efficacy and stability.
dentistry and patient Surgical Technique (PST), has rapidly However, through trial and error and
care. She is published gained popularity over the last few more than 100 cases completed with
in the Journal of the
American Academy of
years but is poorly understood by a minimum of one-year follow-up, I
Periodontology. many clinicians. Even more confusing have established some guidelines that
Conflict of Interest is the fact that there are numerous I use in my decision-making process
Disclosure: None reported. options available for gingival recession when considering treatment options
treatment, each with its own benefits for recession defects. The purpose of
and limitations. As a periodontist well this discussion is to elucidate how
trained in a vast array of techniques, PST is performed, review its benefits
incorporating PST into my practice and limitations and share my personal
four years ago was a bit of a treatment- decision-making process in order to
planning challenge. Like many assist other clinicians in determining
periodontists, my preferred technique when this procedure would be a viable
had been subepithelial connective treatment option as well as answer some
tissue grafting because of its ability to of the most commonly asked questions
predictably cover exposed root surfaces, regarding this novel technique.

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The most alluring aspect of this

procedure for the general public, and
FIGURES 1. Maxillary central incisors with Class I Miller recession (1A ). One year after PST (1B ).
some clinicians, is that PST does not
require the use of autogenous or allogenic
graft material (tissue harvested from a
different site from the same patient or
from a cadaver, respectively). Instead,
the patient’s existing gingiva is simply
moved coronally to cover the exposed root
surface. This is achieved using a 16-gauge
sterile hypodermic needle to penetrate the
alveolar mucosa and pierce the periosteum
apical to the recessed area creating a
“pinhole” through which instruments
can be inserted. In cases with multiple
adjacent sites, multiple pinholes may be
required. Specifically designed instruments
are inserted through the pinhole to elevate
a full-thickness flap without severing FIGURE 2C .
the interproximal papillae to move the FIGURE 2D.
tissue to the desired coronal position. In FIGURES 2 . 2A and 2B show pretreatment of Class II Miller recession defects with thin biotype and no attached
my mind, I thought of the PST elevation gingiva on teeth Nos. 21, 23, 28. 2C and 2D are one year after PST and demonstrate complete root coverage.
technique to be an alternative method
for achieving a full-thickness flap while
keeping the papillae intact, similar to tissue support to secure the marginal more lateral extension and flap release will
popular tunneling and modified tunneling gingiva in the new position. The use be required to allow tension-free coronal
procedures6,7 or the vestibular incision of such a membrane is not new in the advancement of the gingival margin
subperiosteal tunnel access (VISTA) periodontal literature and has a long at the site of recession. For this reason,
technique,8 which many surgeons utilize history of being safe and effective both many of my patients prefer a technique
to prepare a site for graft placement. in the treatment of gingival recession10 that allows for a smaller surgical area, like
A critical factor for the success of as well as periodontal regeneration.11 a subepithelial connective tissue graft
most root-coverage procedures is the The elimination of the need for sutures with a double papilla flap technique.12
elimination of tension on the gingival is another unique aspect of this procedure. Postsurgically, the pinhole is left
margin of the newly positioned tissue.9 In order to allow tension-free coronal to heal by primary intention without
With PST, wound stabilization is repositioning of the gingival margin suturing and is often healed within 48
achieved with the use of a malleable, without using sutures, it is necessary to hours. Patients are instructed to bathe the
noncross-linked bioresorbable porcine also elevate and coronally advance the surgical area with 0.12% chlorhexidine
collagen membrane (Bio-Gide, Geistlich, gingival tissues of several adjacent teeth, gluconate oral rinse and avoid brushing
Princeton, N.J.) that is carefully inserted both mesially and distally to the treatment or flossing the area for six to 12 weeks.
through the pinhole and tucked under area. This requirement is of clinical Although patients experience very little
the gingival tissues, over the root significance for some patients who want to pain following the procedure, there can
surfaces, supporting the flap in the minimize the area of treatment for faster be a considerable amount of swelling
desired coronal position, without the recovery. For example, it would not be that subsides after about seven days. The
need for suturing, dressings or tissue uncommon to require release from first collagen membrane is slowly resorbed
adhesive. Wound stabilization is thus molar to first molar to treat a single, deep over the next three to four months, as
achieved by distending the flap with the recession defect of a mandibular incisor. the newly coronally advanced gingiva
collagen membrane, resulting in adequate The more severe the recession defect, the settles and re-establishes periodontal
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attachment to the previously exposed treatments. Miller explained that class I support these claims. When discussing
root surface. Histological studies are and II recession defects can expect 100 treatment options with my patients,
currently lacking to determine the exact percent root coverage, class III defects they are fully informed of this fact
biology of the healing process, either can expect only partial root coverage and and it is left to them to make an
connective tissue attachment, long class IV defects are highly unpredictable educated decision. They usually choose
junctional epithelium or perhaps even and little to no root coverage can be subepithelial grafting in cases where
some bone regeneration. Clinically, expected due to the presence of horizontal there is only a single tooth with little
probing depths usually range from 1–3 mm bone loss and loss of interdental papillae. to no attached keratinized gingiva.
when measured six months after surgery. These same guidelines should apply Initially, I only offered PST to patients
Like all surgical techniques, there are to PST as well. Additional limitations who have ample attached gingiva and
limitations to the success of PST that include the inability to treat recession thick phenotypes (F I G U R E 1 ). However,
must be considered when determining defects located on palatal surfaces, after my experience with the procedure
treatment options. Most important, the difficulty in physically accessing and witnessing first-hand some of the
patient must be healthy enough to be mandibular lingual areas using the PST dramatic results it can produce, I began
considered a surgical candidate, similar to offer it for more complex cases (F I G U R E
to all the other treatment modalities. 2 ). In cases where there are several
Heavy smoking, uncontrolled or teeth in a single arch with recession
poorly controlled diabetes and certain and minimal attached gingiva, patients
medications are just some of the factors
Patients should be free often want to try PST over the multiple
that can compromise the healing process of active periodontal rounds of surgery required for connective
and increase the risk of complications,1 disease or severe gingival tissue grafting of an entire arch. F I G U R E 2
which may outweigh the benefit of inflammation prior to demonstrates that good root coverage and
treating the condition at all. As with some gain in attached gingiva is possible
other root-coverage therapies, patients performing PST. with PST and I consider it an acceptable
should be free of active periodontal treatment option despite the lack of
disease or severe gingival inflammation documented stability, as long as patients
prior to performing PST and should are made aware of this fact. Additionally,
demonstrate compliance with periodontal protocol and instruments and anatomical I evaluate the gingival phenotype of
recall appointments and home care considerations involving the sublingual the recession site and explain that PST
instructions. Also similar to other surgical spaces and related structures that may might not alter it significantly, increasing
therapies, occlusal discrepancies and present significant risk in an apical-style the risk of recurrence. Due to the lack
nocturnal bruxism or clenching should be approach for mandibular lingual surfaces. of evidence regarding the long-term
appropriately identified and managed. When considering soft tissue stability of PST in cases with very thin
There are many anatomical factors biotype and attached keratinized biotypes and minimal or no attached
to account for when considering gingiva, autogenous grafting is the most gingiva, I ensure that these patients
treatment options, including but not documented procedure demonstrating understand that additional procedures
limited to location of defect, severity of predictable and stable increases in may be required if the desired results
defect, presence or absence of bone loss, tissue volume, i.e., altering the soft are not achieved, although I have yet
number of teeth involved, amount of tissue biotype and amount of attached to see such recurrence. This word of
attached keratinized gingiva and gingival keratinized gingiva.2–5 However, caution is based on existing studies
phenotype. Miller’s classification of analogous to alternative treatment involving coronally positioned flaps
gingival recession13 is the most widely modalities including allogenic soft tissue that suggest a minimum tissue thickness
used method for categorization of the grafting and guided tissue regeneration, of 0.8–1mm for predictable and stable
different types and severities of recession anecdotal evidence suggests that PST root coverage.15–17 Notwithstanding
defects and is useful to establish general is capable of increasing tissue volume these limitations, there are some unique
guidelines for clinicians when predicting and attached keratinized gingiva,14 but and significant advantages to PST
the success of various gingival recession currently there is limited evidence to for both the patient and clinician.
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Compared to conventional FIGURE 3B .

autogenous soft tissue grafting, patients
anecdotally report reduced postoperative
pain with the elimination of a secondary FIGURES 3 . Grade IV Miller recession due to horizontal bone loss (3A ). One year after PST and showing 100
percent coverage on two of six sites and 50–70 percent coverage on four of six sites (3B ). Note the black triangle
harvest site.1 This fact may also improve
between the central incisors remains after treatment.
case acceptance for PST due to the
perceived pain associated with autogenous
grafting and other alternative techniques. the gingival margin and connective together with a shift to patient-centered
Patient-centered investigations are tissue attachment beyond the outcomes, has driven the development
needed to substantiate these notions. cementoenamel junction onto enamel or of alternative therapies with improved
An additional advantage of PST over over restorative surfaces. This limitation patient acceptance and less overall
autogenous grafting procedures is the applies to PST as well. However, PST patient morbidity (pain, swelling and
ability to treat an unlimited number of can be used to cover noncarious cervical bleeding) compared to autogenous
sites at one time because the clinician is lesions as well as previously restored or grafting. Additionally, the inherent
not limited by the ability to harvest an decayed root surfaces, similar to other limitation in the availability of donor
adequate amount of tissue to cover the methods for treating gingival recession. tissue when performing autogenous
desired area. In contrast to most other Although common in practice, the grafting has compelled clinicians to
procedures commonly performed for the removal of a restoration to eliminate explore other methods. As a result,
reversal of gingival recession, PST also recurrent decay or improve gingival clinicians are now faced with a plethora
does not require sutures, reducing the aesthetics, in combination with a of treatment modalities for achieving
time required to perform the procedure root-coverage procedure, is a relatively root coverage. Systematic reviews and
and eliminating the overhead cost of recent concept in the literature.24–28 consensus statements produced as a result
suture and related surgical instruments. Another misconception regarding of the recent American Academy of
Moreover, the usage of a noncross-linked root-coverage procedures in general Periodontology regeneration workshop
bioresorbable collagen membrane with is related to the ability to predictably concluded that viable alternative
PST may encourage bone regeneration attain significant root coverage in treatment modalities are currently
similar to that noted in the literature the presence of horizontal bone loss. available that are capable of achieving
regarding guided tissue regeneration for This type of recession often results in root coverage and providing keratinized
the treatment of gingival recession,18–21 cosmetic compromise due to the lack tissue augmentation without the need
however, histological evidence is of interproximal papillae, commonly for palatal donor tissue.29 To date, the
needed to support this theory. referred to as “black triangles.” only peer-reviewed published clinical
PST is not taught in universities Analogous to other procedures,13 PST research to date that is specific to PST
and clinicians must attend a specific does not predictably fill these spaces is a retrospective study of 100 sites
privately taught course to learn how to (FIGURE 3 ). A final question many treated with PST that found an average
perform the procedure, causing many unfamiliar with the technique have is of 86.9 percent defect coverage and an
untrained clinicians to be unclear about in relation to the mental nerve. Due average residual recession of only 0.4
its limitations. Some of the limitations to the apicocoronal approach required mm.8 Average follow-up period was 18
of PST are not exclusive to this one with PST, special consideration must months, comparable to other long-term
particular procedure because it is due to be taken to avoid damage to the mental studies evaluating the stability of root-
the biologic nature of the periodontal nerve, a concern that is addressed coverage procedures.1,4,6 Research is
attachment apparatus itself. It is well with a simple modification to the currently in progress to further examine
accepted in the periodontal community technique taught during the training. the efficacy, predictability, limitations
that connective tissue attachment An increased understanding of the and long-term stability of PST. In
will only form on cementum and not importance of treating gingival recession conclusion, many treatment modalities are
restorative surfaces or enamel.22,23 and the establishment of an adequate available for the purpose of root coverage,
Therefore, there is currently no procedure zone of attached keratinized gingiva in and PST is yet another treatment
that will predictably coronally advance preventing clinical attachment loss, option for clinicians to consider. ■
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DISCLOSURE Thickness a Relevant Predictor to Achieve Root coverage? A

John Chao, DDS, holds patents for PST instruments and 19-Case Series. J Periodontol 1999;70:1077–1084.
trademarks for the Pinhole Surgical Technique. 16. Berlucchi I, Francetti L, Del Fabbro M, Basso M,
Weinstein RL. The Influence of Anatomical Features on the
ACKNOWLEDGMENT Outcome of Gingival Recessions Treated With Coronally
The author thanks Richard Nagy, DDS, for inviting her to write Advanced Flap and Enamel Matrix Derivative: A One-Year
an article for this issue of the Journal. Prospective Study. J Periodontol 2005;76:899–907.
17. Huang LH, Neiva RE, Wang HL. Factors Affecting the
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Dent 2012;32:521–531. THE AUTHOR,
Tina M. Beck, DDS, MS, can be reached at
15. Baldi C, Pini-Prato G, Pagliaro U, et al. Coronally
Advanced Flap Procedure for Root coverage: Is Flap

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